Documentation that an FDA-approved medication for alcohol or drug dependence was prescribed at hospital discharge.

Suggested Data Collection Question:

Did the patient receive at discharge a prescription for one of the FDA approved medications for alcohol or drug dependence?

Format:

Length:

1

Type:

Alphanumeric

Occurs:

1

Allowable Values:

1 The patient received at discharge a prescription for an FDA-approved medication for alcohol or drug dependence

2 A prescription for an FDA-approved medication for alcohol or drug dependence was offered at discharge and the patient refused

3 A prescription for an FDA-approved medication for alcohol or drug dependence was not offered at discharge, or unable to determine from medical record documentation.

Notes for Abstraction:

In determining whether a medication for alcohol or drug dependence was prescribed at discharge, it is not uncommon to see conflicting documentation among different medical record sources. For example, the discharge summary may list Disulfiram but this is not included in any of the other discharge medications sources, e.g., discharge orders. All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.

In cases where there is a medication for alcohol or drug dependence in one source and it is not mentioned on other sources, it should be interpreted as a discharge medication, select value 1 unless documentation elsewhere in the medical record suggests that it was not prescribed at discharge.

If documentation is contradictory (physician noted “d/c Antabuse” or “hold Antabuse” in the discharge orders, but Antabuse is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc, documentation raises enough questions, the case should be deemed unable to determine, select value 3

Suggested Data Sources:

Discharge summary

Transfer sheet

Discharge Instruction Sheet

Medication Reconciliation Form

Nursing Discharge notes

Physician Order Sheets

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Refer to Appendix B, Table 12.2 for a comprehensive list of FDA-approved medications for alcohol and drug dependence